Form 1099-R 2021 Form 1099-R 2021 - RRD

[Pages:2]Form 1099-R

1 Gross distribution

$ 2b Taxable amount

not determined

CORRECTED (if checked) 2a Taxable amount

$ Total distribution

2021 OMB No. 1545-0119

Distributions From Pensions, Annuities, Retirement or

Profit-Sharing Plans, IRAs, Insurance Contracts, etc.

12 FATCA Filing 13 Date of payment

requirement

Form 1099-R

1 Gross distribution

$ 2b Taxable amount

not determined

CORRECTED (if checked)

2a Taxable amount

$ Total distribution

2021 OMB No. 1545-0119 Distributions From Pensions, Annuities, Retirement or Profit-Sharing Plans, IRAs, Insurance Contracts, etc.

12 FATCA Filing 13 Date of payment

requirement

PAYER'S name, street address, city or town, state or province, country, ZIP or foreign postal code, and phone no. PAYER'S name, street address, city or town, state or province, country, ZIP or foreign postal code, and phone no.

PAYER COPIES

PAYER'S TIN

RECIPIENT'S TIN

PAYER'S TIN

RECIPIENT'S TIN

3 Capital gain (included in box 2a)

4 Federal income tax withheld 5 Employee contributions/Designated

3 Capital gain (included

Roth contributions or insurance premiums

in box 2a)

4 Federal income tax withheld 5 Employee contributions/Designated

Roth contributions or insurance premiums

$

$

$

$

$

$

6 Net unrealized appreciation 7 Distribution code(s)

IRA/ SEP/

8 Other

in employer's securities

SIMPLE

%

6 Net unrealized appreciation in employer's securities

7 Distribution code(s)

IRA/ SEP/

8 Other

SIMPLE

%

$ 9a Your percentage of total distribution

$ 9b Total employee contributions

$ 9a Your percentage of total distribution

$ 9b Total employee contributions

%$ RECIPIENT'S name, street address, city or town, state or province, country, and ZIP or foreign postal code

%$ RECIPIENT'S name, street address, city or town, state or province, country, and ZIP or foreign postal code

Account number (see instructions)

11 1st year of desig. Roth contrib. 10 Amount allocable to IRR within 5 years $

14 State tax withheld $

15 State/Payer's state no.

16 State distribution $

17 Local tax withheld $

18 Name of Locality

19 Local distribution $

Payer's - State, Local or File Copy

Department of the Treasury Internal Revenue Service

Form1099R

Account number (see instructions)

11 1st year of desig. Roth contrib. 10 Amount allocable to IRR within 5 years $

14 State tax withheld $

15 State/Payer's state no.

16 State distribution $

17 Local tax withheld $

18 Name of Locality

19 Local distribution $

Payer's - State, Local or File Copy

Department of the Treasury Internal Revenue Service

Form1099R

Form 1099-R

1 Gross distribution

$ 2b Taxable amount

not determined

CORRECTED (if checked)

2a Taxable amount

$ Total distribution

2021 OMB No. 1545-0119

Distributions From Pensions, Annuities, Retirement or

Profit-Sharing Plans, IRAs, Insurance Contracts, etc.

12 FATCA Filing 13 Date of payment

requirement

Form 1099-R

1 Gross distribution

$ 2b Taxable amount

not determined

CORRECTED (if checked)

2a Taxable amount

$ Total distribution

2021 OMB No. 1545-0119 Distributions From Pensions, Annuities, Retirement or Profit-Sharing Plans, IRAs, Insurance Contracts, etc.

12 FATCA Filing 13 Date of payment

requirement

PAYER'S name, street address, city or town, state or province, country, ZIP or foreign postal code, and phone no. PAYER'S name, street address, city or town, state or province, country, ZIP or foreign postal code, and phone no.

PAYER COPIES

PAYER'S TIN

RECIPIENT'S TIN

PAYER'S TIN

RECIPIENT'S TIN

3 Capital gain (included in box 2a)

4 Federal income tax withheld 5 Employee contributions/Designated

3 Capital gain (included

Roth contributions or insurance premiums

in box 2a)

4 Federal income tax withheld 5 Employee contributions/Designated

Roth contributions or insurance premiums

$

$

$

$

$

$

6 Net unrealized appreciation 7 Distribution code(s)

IRA/ SEP/

8 Other

% 6 Net unrealized appreciation 7 Distribution code(s)

IRA/ SEP/

8 Other

%

in employer's securities

SIMPLE

6 in employer's securities

SIMPLE

$ 9a Your percentage of total distribution

$ 9b Total employee contributions

$ 9a Your percentage of total distribution

$ 9b Total employee contributions

%$ RECIPIENT'S name, street address, city or town, state or province, country, and ZIP or foreign postal code

%$ RECIPIENT'S name, street address, city or town, state or province, country, and ZIP or foreign postal code

Account number (see instructions)

11 1st year of desig. Roth contrib. 10 Amount allocable to IRR within 5 years $

14 State tax withheld $

15 State/Payer's state no.

16 State distribution $

17 Local tax withheld $

18 Name of Locality

19 Local distribution $

Payer's - State, Local or File Copy

Department of the Treasury Internal Revenue Service

Form1099R

Account number (see instructions)

11 1st year of desig. Roth contrib. 10 Amount allocable to IRR within 5 years $

14 State tax withheld $

15 State/Payer's state no.

16 State distribution $

17 Local tax withheld $

18 Name of Locality

19 Local distribution $

Payer's - State, Local or File Copy

LR4R

Department of the Treasury Internal Revenue Service Form1099R

5176

Instructions for Payer

To complete Form 1099-R, use: ? The 2021 General Instructions for Certain Information Returns, and ? The 2021 Instructions for Forms 1099-R and 5498.

To order these instructions and additional forms, go to Form1099R. Caution: Because paper forms are scanned during processing, you cannot file Forms 1096, 1097, 1098, 1099, 3921, or 5498 that you print from the IRS website. Due dates. Furnish Copies B, C, and 2 of this form to the recipient by January 31, 2022.

File Copy A of this form with the IRS by February 28, 2022. If you file electronically, the due date is March 31, 2022. To file electronically, you must have software that generates a file according to the specifications in Pub. 1220. The IRS does not provide a fill-in form option for Copy A. Need help? If you have questions about reporting on Form 1099-R, call the information reporting customer service site toll free at 866-455-7438 or 304-263-8700 (not toll free). Persons with a hearing or speech disability with access to TTY/TDD equipment can call 304-579-4827 (not toll free).

1099-R / COPY D

Instructions for Payer

To complete Form 1099-R, use: ? The 2021 General Instructions for Certain Information Returns, and ? The 2021 Instructions for Forms 1099-R and 5498.

To order these instructions and additional forms, go to Form1099R. Caution: Because paper forms are scanned during processing, you cannot file Forms 1096, 1097, 1098, 1099, 3921, or 5498 that you print from the IRS website. Due dates. Furnish Copies B, C, and 2 of this form to the recipient by January 31, 2022.

File Copy A of this form with the IRS by February 28, 2022. If you file electronically, the due date is March 31, 2022. To file electronically, you must have software that generates a file according to the specifications in Pub. 1220. The IRS does not provide a fill-in form option for Copy A. Need help? If you have questions about reporting on Form 1099-R, call the information reporting customer service site toll free at 866-455-7438 or 304-263-8700 (not toll free). Persons with a hearing or speech disability with access to TTY/TDD equipment can call 304-579-4827 (not toll free).

1099-R / COPY D

Instructions for Payer

To complete Form 1099-R, use: ? The 2021 General Instructions for Certain Information Returns, and ? The 2021 Instructions for Forms 1099-R and 5498.

To order these instructions and additional forms, go to Form1099R. Caution: Because paper forms are scanned during processing, you cannot file Forms 1096, 1097, 1098, 1099, 3921, or 5498 that you print from the IRS website. Due dates. Furnish Copies B, C, and 2 of this form to the recipient by January 31, 2022.

File Copy A of this form with the IRS by February 28, 2022. If you file electronically, the due date is March 31, 2022. To file electronically, you must have software that generates a file according to the specifications in Pub. 1220. The IRS does not provide a fill-in form option for Copy A. Need help? If you have questions about reporting on Form 1099-R, call the information reporting customer service site toll free at 866-455-7438 or 304-263-8700 (not toll free). Persons with a hearing or speech disability with access to TTY/TDD equipment can call 304-579-4827 (not toll free).

1099-R / COPY D

Instructions for Payer

To complete Form 1099-R, use: ? The 2021 General Instructions for Certain Information Returns, and ? The 2021 Instructions for Forms 1099-R and 5498.

To order these instructions and additional forms, go to Form1099R. Caution: Because paper forms are scanned during processing, you cannot file Forms 1096, 1097, 1098, 1099, 3921, or 5498 that you print from the IRS website. Due dates. Furnish Copies B, C, and 2 of this form to the recipient by January 31, 2022.

File Copy A of this form with the IRS by February 28, 2022. If you file electronically, the due date is March 31, 2022. To file electronically, you must have software that generates a file according to the specifications in Pub. 1220. The IRS does not provide a fill-in form option for Copy A. Need help? If you have questions about reporting on Form 1099-R, call the information reporting customer service site toll free at 866-455-7438 or 304-263-8700 (not toll free). Persons with a hearing or speech disability with access to TTY/TDD equipment can call 304-579-4827 (not toll free).

1099-R / COPY D

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